This aim of this document is to provide guidance for people supporting adults with care and support needs who are at risk of harm as a result of self-neglect.
Managing the balance between protecting adults from self-neglect and their right to self-determination is a challenge for professionals. The guidance aims to support good practice in this area.
The Care Act (2014)
Self-neglect and safeguarding adults
The Care Act (2014) was implemented in April 2015 and brought about a number of changes which impact upon how self-neglect cases are dealt with.
Within the accompanying statutory guidance for the Care Act (2014), new categories of abuse were added, with “self-neglect” specifically mentioned. As a result, self-neglect is now incorporated as a form of abuse and neglect covered by multi-agency safeguarding adults policy and procedures. The statutory guidance’s definition of self-neglect is as follows:
“self-neglect – this covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding”. The statutory guidance identifies that it can be difficult to assess self-neglect. Specifically, that it may be difficult to distinguish between whether a person is making a capacitated choice to live in a particular way (which may be described as unwise) or whether the person lacks mental capacity to make the decision.
Other key changes (of relevance to how self-neglect is dealt with under the safeguarding adults framework) include the removal of a significant harm threshold and that the adult at risk does not need to be eligible for social care services for a safeguarding adults enquiry to commence.
Duty of cooperation
The Care Act (2014) now makes integration, cooperation and partnership a legal requirement on local authorities and on all agencies involved in public care, including, the NHS, independent or private sector organisations, housing and the Police. Cooperation with partners should enable earlier intervention - the best way to prevent, reduce or delay needs for care and support and safeguard adults at risk from abuse or neglect.
The Care Act (2014) places significant emphasis on the wellbeing principle with decisions being person-led and outcome-focused. Local authorities must promote wellbeing when carrying out any of their care and support functions in respect of an individual, including when carrying out safeguarding adults enquiries. The wellbeing principle will be an important consideration in responding to self-neglect cases. The definition of wellbeing as defined in the Care Act relates to the following areas:-
• personal dignity (including treatment of the individual with respect);
• physical and mental health and emotional wellbeing;
• protection from abuse and neglect;
• control by the individual over day to day life ( including over care and support provided and the way it is provided);
• Participation in work, education, training or recreation;
• Suitability of living accommodation;
• The individuals contribution to society.
Definitions of self-neglect
Whilst there is currently no standard definition of self-neglect, in addition to the Care Act (2014) definition above, research has suggested that there are three recognised forms of self-neglect which include:
Lack of self-care – this may involve neglecting personal hygiene, nutrition and hydration or health. This type of neglect would involve a judgement to be made about what is an acceptable level of risk and what constitutes wellbeing.
Lack of care of one’s environment – this may result in unpleasant or dirty home conditions and an increased level of risk in the domestic environment such as health and safety and fire risks associated with hoarding2. This may again be subjective and require a judgement call to determine whether the conditions within an individual’s home environment are acceptable.
Refusal of services that could alleviate these issues – this may include the refusal of care services, treatment, assessments or intervention, which could potentially improve self-care or care of one’s environment.
Indicators of self-neglect
Neglecting personal hygiene impacting upon health.
Neglecting home environment, with an impact upon health and wellbeing and public health issues. This may also lead to hazards in the home due to poor maintenance. Not disposing of refuse leading to infestations.
Poor diet and nutrition leading to significant weight loss or other associated health issues.
Lack of engagement with health and other services/ agencies.
Hoarding items – excessive attachment to possessions, people who hoard may hold an inappropriate emotional attachment to items.
Large number of pets.
Factors that may lead toindividuals being overlooked:-
The perception that this is a “lifestyle choice.”
Poor multiagency working and lack of information sharing.
Lack of engagement from the individual or family; challenges presented by the individual or family making it difficult for professionals to work with the individual to minimise risk.
An individual in a household is identified as a carer without a clear understanding of what their role includes which can lead to assumptions that support is being provided when it is not.
A de-sensitisation to well known cases, resulting in minimisation of need and risk.
An individual with mental capacity making unwise decisions, withdrawing from agencies however continuing to be at risk of significant or serious harm.
Individuals with chaotic lifestyles and multiple or competing needs.
Inconsistency in thresholds across agencies and teams – level of subjectivity in assessing risk.
Contributing factors which may lead to or escalate self-neglect:-
Age related changes, in physical health or mental health.
Bereavement/ traumatic event.
Chronic mental health difficulty.
Alcohol or drug dependency/ misuse
Fear and anxiety.
Learning from Safeguarding Adult Reviews Over the years various local authorities have examined findings from Serious Case Reviews, now termed Safeguarding Adult Reviews. This is a summary of some of the findings:-
The importance of thorough and robust risk assessment and planning.
The importance of face-to-face reviews.
The need for clear interface with safeguarding adults procedures.
The importance of effective collaboration between agencies.
Increased understanding of the legislative options available to intervene to safeguard a person who is self-neglecting.
The importance of the application and understanding of the Mental Capacity Act (2005).
Where an individual refuses services, it is important to consider mental capacity and ensure the individual understands the implications and that this is documented. Services/ support should be re-visited at regular intervals: it may take time for an individual to be ready to accept some support.
The need for practitioners and managers to challenge and reflect upon cases through the supervision process and training.
The need for robust guidance to assist practitioners in working in this complex area.
Assessment processes need to identify who carers are (and significant others – the “whole family approach”) and how much care and/or support they are providing.
The Mental Capacity Act (2005) (MCA) is crucial to determining what action may or may not be taken in self-neglect cases. All adults have a right to take risks and behave in a way that may be construed as self-neglectful, if they have the capacity to do so without interference from the state3.
Mental capacity is a complex attribute, involving not only the ability to understand the consequences of a decision but also the ability to carry out the decision. Where decisional capacity is not accompanied by the ability to carry out the decision, overall capacity is impaired and ‘best interests’ intervention by professionals to safeguard wellbeing may be legitimate. Mental capacity assessments must be decision-specific - apparent capacity to make simple decisions should not result in an assumption that the person is able to make more complex decisions.
Where it is felt intervention may be required due to a person’s self-neglect behaviour, any action proposed must be with the person’s consent where they are assessed as having mental capacity unless there are wider public interest concerns, for example, other people may be at risk of harm or a crime has or may be committed. Examples where other people may be at risk as a result of self-neglect include where there is a fire risk or where there are public health concerns (e.g. infestation affecting other properties).
Where there is a concern around significant self-neglect (see section 7), one of the first considerations should be whether the person has mental capacity to understand the risks associated with their actions/lack of action. As per the first principle of the MCA, a person must be presumed to have capacity to make their own decisions. However, a prior presumption of mental capacity may be revisited in self-neglect cases. This is confirmed by the MCA code of practice which states that one of the reasons why people may question a person’s capacity to make a specific decision is ”the person’s behaviour or circumstances cause doubt as to whether they have capacity to make a decision” (4.35 MCA Code of Practice, p. 52).
Any capacity assessment carried out in relation to self-neglect behaviour must be time specific, and relate to a specific intervention or action. The professional responsible for undertaking the capacity assessment will be the person who is proposing the specific intervention or action, and is referred to as the ‘decision-maker’. Although the decision-maker may need to seek support from other professionals in the multi-disciplinary team, they are responsible for making the final decision about a person’s capacity.
If the person lacks capacity to consent to the specific action or intervention, then the decision maker must demonstrate that they have met the requirements of the best-interests “checklist‟.
In self-neglect cases where there is a risk of significant harm (or higher), it is best practice to demonstrate your assessment (or presumption) of capacity using the MCA1 form and where a best interest decision is required using the MCA2 form.
In particularly challenging and complex cases, it may be necessary for a referral to the Court of Protection to make the best interests decision. Any referral to the Court of Protection should be discussed with legal services and the relevant Safeguarding Adults Manager. Due to the complexity of such cases, there must be a safeguarding strategy meeting to oversee the process.
If a person is assessed as having mental capacity this does not negate the need for action under safeguarding adults procedures, particularly where the risk of harm is deemed to be serious or critical. Where professionals foresee serious/critical harm to a person and they have mental capacity, duty of care extends to gathering all the necessary information to inform a thorough risk assessment and subsequent actions even without the consent of the individual. It may be determined that there are no legal powers to intervene, however it will be demonstrated that risks and possible actions have been fully considered on a multi-agency basis.
In the majority of self-neglect cases, early intervention and preventative actions will negate the need for safeguarding adults procedures to be used. The Care Act (2014) emphasises the importance of using local community support networks and facilities provided by partner and voluntary organisations. Please refer to Appendix 8 for a list of useful of agencies with contact details.
Section 8 provides suggested responses to low-level harm and risk.
Identifying level of risk/harm
Responding to self-neglect will depend on the level of risk/harm that has been identified. Professionals should refer to the Safeguarding Adults Risk Threshold Tool which includes self-neglect as well as considerations about the vulnerability of the individual and the circumstances of the case.
Level 1:Lower Level Risk/Harm - Identifiable risk factors that do not indicate imminent or significant harm to self or others
Level 2: Significant or Very Significant Risk/Harm - Identifiable indicators of significant harm to self or others
Level 3: Critical Risk/Harm - Imminent risk of serious harm to self or others, where the impact on wellbeing would be critical.
Level 1: Low Risk This may include situations where existing information indicates that there are lower level risk factors present and that they are already being managed effectively by one or more practitioners. If a concern is identified as low risk, it is expected that the case is dealt with outside of safeguarding adults procedures and managed by the most appropriate practitioner. Circumstances could include, but are not exclusive to:
Reports that self-neglect is occurring or possible, but where the potential impact and consequence is not considered to be significant or immediate.
Unwillingness to engage with services, accept assessments or offers of support and/ or intervention, but where available information suggests little risk of significant harm;
Non-compliance with medication, which is unlikely to result in significant harm;
Level 2: Significant or Very Significant This may include situations where presenting circumstances indicate risks factors are present that place the adult at risk or others of significant harm through self-neglect, but available information indicates that risk level is not immediate and/or critical. This can include but may not be exclusive to:
Multiple reports of concerns of self-neglect from multiple agencies.
Behaviour which poses a fire risk to self and others.
Lack of care or behaviour (refusal to take prescribed medication, lack of personal care, unsanitary/unhygienic lifestyle or living conditions, substance misuse, dietary disorder) to the extent that health and wellbeing deteriorate significantly e.g. pressure sores, wounds, dehydration, malnutrition, infection.
Where information indicates a history of risk taking behaviour or a prevalence of historical risk factors and there is a likelihood of reoccurrence;
Unwillingness to engage with services, accept assessments or offers of support and/or intervention.
Level 3: Critical This includes the most serious and challenging presenting circumstances, including but not exclusive to:
Complex and high level risk, including the potential for or possibility of death and/or serious injury because of the presenting risks and situation;
A failure to seek/accept lifesaving services or medical care where required;
Apparent lack of options available to protect the individual from risk/harm;
Ongoing behaviour which is likely to continue.
Where the demands of managing the risk may involve the commitment of resources that will require senior management oversight and approval;
Possibility of heightened public awareness, scrutiny or media attention due to the high profile nature of the circumstances.